Ventilation Disorders

Obstructive Disorders
BronchialAsthma,
Chronic Obstructive Pulmonary Disease (COPD)
Infectious/Inflammatory Disorders:
Pleuritis,Pleural Effusion,
 Pneumothorax,
Atelectasis
Asthma
Overview
 ● Asthma is a chronic inflammatory disorder of the airways that results in
intermittent and reversible airflow obstruction of the bronchioles.
 The obstruction occurs either by inflammation or airway hyperresponsiveness.
 Asthma can occur at any age.
 The cause of asthma is unknown.
Asthma

 Is an intermittent, reversible, obstructive airway problem. Characterized by

exacerbations and remissions.
 is a chronic inflammatory disease of the airways that causes airway
hyperresponsiveness, mucosal edema, and mucus production. This
inflammation ultimately leads to recurrent episodes of asthma symptoms:
cough, chest tightness, wheezing, and dyspnea
 is largely reversible, either spontaneously or with treatment. Patients with
asthma may experience symptom-free periods alternating with acute
exacerbations, which last from minutes to hours or days.
 For most patients it is a disruptive disease, affecting school and work
attendance, occupational choices, physical activity, and general quality of
life.
 Asthma

 can occur at any age and is the most common chronic disease of childhood. Despite
increased knowledge regarding the pathology of asthma and the development of
better medications and management plans, the death rate from asthma continues to
increase.
 Allergy is the strongest predisposing factor. Chronic exposure to airway irritants or
allergens also increases the risk for developing asthma. Common allergens can be
seasonal (eg, grass, tree, and weed pollens) or perennial (eg, mold, dust, roaches, or
animal dander).
 Common triggers for asthma symptoms and exacerbations in patients with asthma
include airway irritants (eg, air pollutants, cold, heat, weather changes, strong odors
or perfumes, smoke), exercise, stress or emotional upsets, sinusitis with postnasal
drip, medications, viral respiratory tract infections, and gastroesophageal reflux.
Most people who have asthma are sensitive to a variety of triggers.
 Risks factors/etiology
 Older adult clients have decreased pulmonary reserves due to physiologic lung changes that occur with
the aging process.
o Older adult clients are more susceptible to infections.
o The sensitivity of beta-adrenergic receptors decreases with age. As the beta receptors age and lose sensitivity,
they are less able to respond to agonists, which relax smooth muscle and can result in bronchospasms.
o Family history of asthma
o Smoking
o Secondhand smoke exposure
o Environmental allergies
o Exposure to chemical irritants or dust
o Gastroesophageal reflux disease (GERD)
 Clinical Manifestations
 The three most common symptoms of asthma are
 cough,
 dyspnea, and
 wheezing.
 In some instances, cough may be the only symptom.
 Asthma attacks often occur at night or early in the morning, possibly due to circadian variations that
influence airway receptor thresholds.
 An asthma exacerbation may begin abruptly but most frequently is preceded by increasing symptoms over
the previous few days.
 There is cough, with or without mucus production. At times the mucus is so tightly wedged in the narrowed
airway that the patient cannot cough it up.
 There may be generalized wheezing (the sound of airflow through narrowed airways), first on expiration and
then possibly during inspiration as well.
 Generalized chest tightness and dyspnea occur.
 Expiration requires effort and becomes prolonged.
 As the exacerbation progresses, diaphoresis, tachycardia, and a widened pulse pressure may occur along
with hypoxemia and central cyanosis (a late sign of poor oxygenation).
 Although life-threatening and severe hypoxemia can occur in asthma, it is relatively uncommon. The
hypoxemia is secondary to a ventilation–perfusion mismatch and readily responds to supplemental
oxygenation.
Normal and Asthmatic Lung Changes
 Assessment
 A complete family, environmental, and occupational history is essential.
 To establish the diagnosis, the clinician must determine that periodic symptoms
of airflow obstruction are present, airflow is at least partially reversible, and
other etiologies have been excluded.
 A positive family history and environmental factors, including seasonal changes,
high pollen counts, mold, climate changes (particularly cold air), and air
pollution, are primarily associated with asthma. In addition, asthma is associated
with a variety of occupation-related chemicals and compounds, including metal
salts, wood and vegetable dust, medications (eg, aspirin, antibiotics, piperazine,
cimetidine), industrial chemicals and plastics, biologic enzymes (eg, laundry
detergents), animal and insect dusts, sera, and secretions.
 Diagnostic Procedures
 Pulmonary function tests (PFTs) are the most accurate tests
for diagnosing asthma and its severity.
 Forced vital capacity (FVC) is the volume of air exhaled from full
inhalation to full exhalation.
 Forced expiratory volume in the first second (FEV1) is the volume
of air blown out as hard and fast as possible during the first second
of the most forceful exhalation after the greatest full inhalation.
 Peak expiratory flow is the fastest airflow rate reached during
exhalation.
 A decrease in FEV1 by 15% to 20% below the expected value is
common in clients who have asthma. An increase in these values by
12% following the administration of bronchodilators is diagnostic
for asthma.
A chest x-ray is used to diagnose changes in the client’s
chest structure over time.
 Assessing the Severity

If the FEV1/FVC ratio is found to be abnormal, it's important to take the next step,
which is grading the abnormality to determine the severity of the condition. The
American Thoracic Society has set specific guidelines for this purpose

Abnormal FEV1 and FVC Results

FEV1/FVC Ratio Severity of Condition  

> 70% Mild  

60 to 69% Moderate  

50 to 59% Moderately Severe  

35 to 49% Severe  

< 34% Very Severe

 Diagnostic findings
 During acute episodes, sputum and blood tests may disclose eosinophilia
(elevated levels of eosinophils). Serum levels of immunoglobulin E may be
elevated if allergy is present.
 Arterial blood gas analysis and pulse oximetry reveal hypoxemia during acute
attacks.
 Initially, hypocapnia and respiratory alkalosis are present.
 As the condition worsens and the patient becomes more fatigued, the PaCO2 may rise.
A normal PaCO2 value may be a signal of impending respiratory failure. Because CO2 is
20 times more diffusible than oxygen, it is rare for PaCO2 to be normal or elevated in
a person who is breathing very rapidly.
 During an exacerbation, the FEV1 and FVC are markedly decreased but improve with
bronchodilator administration (demonstrating reversibility).
 Pulmonary function is usually normal between exacerbations.
Laboratory Tests

 ABGs
 Hypoxemia (decreased PaO2 less than 80 mm Hg) ☐
 Hypocarbia (decreased PaCO2 less than 35 mm Hg – early in attack) ☐ \
 Hypercarbia (increased PaCO2 greater than 45 mm Hg – later in attack)
Management
 Immediate intervention is necessary because the continuing and progressive
dyspnea leads to increased anxiety, aggravating the situation.
 Two general classes of asthma medications are long-acting medications to
achieve and maintain control of persistent asthma and quick-relief
medications for immediate treatment of asthma symptoms and
exacerbations
 Because the underlying pathology of asthma is inflammation, control of
persistent asthma is accomplished primarily with regular use of anti-
inflammatory medications. These medications have systemic side effects
when used long term.
Long-Acting Control Medications.
 Corticosteroids are the most potent and effective anti-inflammatory
medications currently available.
 They are broadly effective in alleviating symptoms, improving airway function, and
decreasing peak flow variability. Initially, the inhaled form is used.
 A spacer should be used with inhaled corticosteroids and the patient should rinse
the mouth after administration to prevent thrush, a common complication of
inhaled corticosteroid use.
 A systemic preparation may be used to gain rapid control of the disease; to manage
severe, persistent asthma; to treat moderate to severe exacerbations; to
accelerate recovery; and to prevent recurrence (Dhand, 2000).
 Corticosteroids, such as fluticasone (Flovent) and prednisone (Deltasone)
 ☐ Leukotriene antagonists, such as montelukast (Singulair), mast cell
stabilizers, such as cromolyn sodium (Intal), and monoclonal antibodies, such
as omalizumab (Xolair)
Nursing Considerations
 ☐ Watch the client for decreased immunity function.
 ☐ Monitor for hyperglycemia.
 ☐ Advise the client to report black, tarry stools.
 ☐ Observe the client for fluid retention and weight gain. This can be common.
 ☐ Monitor the client’s throat and mouth for aphthous lesions (canker sores).
 ☐ Omalizumab can cause anaphylaxis.
 Client Education
 ☐ Encourage the client to drink plenty of fluids to promote hydration.
 ☐ Encourage the client to take prednisone with food.
 ☐ Advise client to use this medication to prevent asthma, not for the onset of an
attack.
 ☐ Encourage client to avoid persons with respiratory infections.
 ☐ Use good mouth care.
 ☐ Do not stop the use of this type of medication suddenly.
 Bronchodilators (inhalers)
 ■ Short-acting beta2 agonists, such as albuterol (Proventil, Ventolin), provide
rapid relief of acute symptoms and prevent exercise-induced asthma.
 ■ Anticholinergic medications, such as ipratropium (Atrovent), block the
parasympathetic nervous system. This allows for the sympathetic nervous system
effects of increased bronchodilation and decreased pulmonary secretions. These
medications are long-acting and used to prevent bronchospasms.
 ■ Methylxanthines, such as theophylline (Theo-24), require close monitoring of
serum medication levels due to a narrow therapeutic range. Use only when other
treatments are ineffective.
 ■ Long-acting beta2 agonists, such as salmeterol (Serevent), primarily are used
for asthma attack prevention.
Nursing Considerations

 ☐ Theophylline – Monitor the client’s serum levels for toxicity. Side effects
will include
 tachycardia, nausea, and diarrhea.
 ☐ Albuterol – Watch the client for tremors and tachycardia.
 ☐ Ipratropium – Observe the client for dry mouth.
Client Education
 ☐ Ipratropium – Advise the client to suck on hard candies to help relieve
dry mouth; increase fluid intake; and report headache, blurred vision, or
palpitations, which may indicate toxicity of ipratropium. Monitor the
client’s heart rate.
 ☐ Salmeterol – Advise client to use to prevent an asthma attack and not
at the onset of an attack
Combination agents (bronchodilator and
anti-inflammatory)
 ■ Ipratropium and albuterol (Combivent)
 ■ Fluticasone and salmeterol (Advair)
 ■ If prescribed separately for inhalation administration at the same time,
administer the bronchodilator first in order to increase the absorption of the
anti-inflammatory agent.
Teamwork and Collaboration
 ◯ Respiratory services should be consulted for inhalers and breathing
treatments for airway management.
 ◯ Nutritional services can be contacted for weight loss or gain related to
medications or diagnosis.
 ◯ Rehabilitation care can be consulted if the client has prolonged weakness
and needs assistance with increasing level of activity
 Complications

 ● Respiratory failure
 Persistent hypoxemia related to asthma can lead to respiratory failure.
 Nursing Actions
 Monitor oxygenation levels and acid-base balance.
 Prepare for intubation and mechanical ventilation as indicated.

 Status asthmaticus
 This is a life-threatening episode of airway obstruction that is often unresponsive to common
treatment. It involves extreme wheezing, labored breathing, use of accessory muscles,
distended neck veins, and creates a risk for cardiac and/or respiratory arrest.
 Nursing Actions
 ■ Prepare for emergency intubation.
 ■ As prescribed, administer oxygen, bronchodilators, epinephrine, and initiate systemic steroid
therapy.